The PULSE Study: Paramedic Upgrade and Life Support Evaluation

To evaluate the impact of introducing a regional advanced care paramedic program on clinical outcomes for patients with out-of-hospital cardiac arrest transported to hospital by emergency medical services (EMS).

We conducted a health records review of adult out-of-hospital cardiac arrest patients transported by emergency medicine services (EMS) to a Canadian tertiary care hospital between 2010 and 2014 (pre-implementation) and 2016 and 2019 (post-implementation) of a regional advanced care paramedic program. The transition year (2015) was excluded due to a phased rollout. Eligible patients were 18 years of age or older who experienced an out-of-hospital cardiac arrest. Patients with traumatic or overdose-related arrests were excluded. Primary outcomes were sustained return of spontaneous circulation, survival to hospital admission, and survival to hospital discharge. Multivariable logistic regression adjusted for witnessed arrest, bystander CPR, initial rhythm, and epinephrine administration.

A total of 390 patients met inclusion criteria, with 228 in the pre-implementation group and 162 in the post-implementation group. Survival to hospital admission increased from 14.9 to 24.7% (adjusted odds ratio [aOR] 2.1, 95% confidence interval [CI] 1.2-3.7) and survival to hospital discharge increased from 3.1 to 11.1% (aOR 5.0, 95% CI 2.0-12.3). Return of spontaneous circulation occurred more frequently with borderline statistical significance after adjustment (aOR 1.5, 95% CI 1.0-2.4). No other changes in prehospital protocols or hospital-based cardiac arrest care occurred during the study period.

The implementation of an advanced care paramedic program was associated with significantly improved survival among out-of-hospital cardiac arrest patients transported to hospital by EMS. EMS systems with developing airway management, vascular access, and resuscitation capabilities may achieve meaningful outcome gains through strategic integration of advanced care paramedic providers into cardiac arrest response frameworks.